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PI ModelPI ModelPI ModelPI Model
Mike Davies, MD FACPMike Davies, MD FACP
““Improving our work Improving our work IS our workIS our work, not a , not a distraction from distraction from
work!”work!”
““Improving our work Improving our work IS our workIS our work, not a , not a distraction from distraction from
work!”work!”““All teach all learn”All teach all learn”
““Healthcare is a team sport”Healthcare is a team sport”
Discussion• Think of a “big change” that was
not implemented very well….• What Went Wrong?
Why change strategies often don’t
work
• Lots of planning then lots of implementing– Analysis paralysis– Lack of consensus on problem and
solution– Risky change process
Why change strategies often don’t work
• Pushing one solution/idea– One person’s perspective– How do we know it works?– Lack of agreement– Ignores all of the
context/circumstances
Improvement Involves “Experimentation”
• Setting aims/goals• Generating ideas • Testing • Measuring progress• Reflection
Lots of activity doesn’t necessarily mean lots of
improvement!• Focus changes on aims and goals• Are the changes we’re making really an
improvement (according to the aims and goals)?– Avoid the “my idea” trap– Take the emotion out – Measure!
-“It is not enough to be busy, so are the ants. The question is, what are you so busy about?”
Thoreau
3 Questions• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an improvement?
Nolan
A Model for Improvement
PLAN
DOSTUDY
ACT
Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996
What is our aim? How will we know a change is an improvement?What changes can we make to make an improvement?
Plan the test: the experiment
Execute itAssess the results
Act differentlythe next time
The ‘unofficial version’!• Hunch
– What could be happening here?• Test
– Let’s try something different• Reflect
– How did it work?• Change
– Should we keep doing it?
From Sarah Frasier
“Kinds” of Data• Judgment
– Research– Performance appraisal – “do something TO you”
• Improvement– Process improvement efforts– “do something WITH you”
Average Cycle Time Run Chart
29
39
49
59
69
79
89
99
109
119
129
11/15
/2004
11/16
/2004
11/17
/2004
11/18
/2004
11/19
/2004
11/20
/2004
11/21
/2004
11/22
/2004
11/23
/2004
11/24
/2004
11/25
/2004
11/26
/2004
11/27
/2004
11/28
/2004
11/29
/2004
Min
utes
Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
APS
D
A P
S D
D SP A
DATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
PDSA Cycles• Are Not Plans!• Are small in scale
– Thinking months – think weeks; thinking weeks – think days; thinking days – think hours
– Thinking facility – think unit; thinking unit – think teams; thinking teams, think ONE team
– Thinking all patients – think a type of patient; thinking a type of patient, think a sample; thinking sample then 3-5 may be enough
Exercise
• AIM- find the rule underlying a series of numbers
• Measure - feedback from the instructor• Changes - are new ideas suggested by
the team
PDSA Test ResultsT eam Cycle Sequence to T est Correct Incorrect
1
2
3
4
5
6
7
8
9
10
11
12
13
14
PA
S A
P
DS
A
P
DS
A
P
DS
A
Small Scale Test
Follow-up Tests
Wider Tests
ImplementationDATA
HunchTheoryIdea
ChangesRepeat PDSA
How to Implement a Change
Belief thatchange willresult inimprovement
High
Low
SuccessfulChange
Unsuccessful Change
Still Needs Further Testing
Developing Testing Implementing
From Lloyd Provost
PA
S A
P
DS
A
P
DS
A
P
DS
A
PA
S A
P
DS
A
P
DS
A
P
DS
A
PA
S A
P
DS
A
P
DS
A
P
DS
A
BalanceDemandAnd Supply
DecreaseAppt. Types Decrease
Demand
Readiness for ChangeCurrent State Resistant Neutral Ready
LowConfidence
th a t ch a n g e willle a d to
imp ro ve me n t
Largecos t offailure
Ve ry SmallScale Te st
Ve ry SmallScale Te st
Ve ry SmallScale Te st
Smallco st o ffailu re
Ve ry SmallScale Te st
Ve ry SmallScale Te st
Small ScaleT est
HighConfidence
th a t ch a n g e willle a d to
imp ro ve me n t
Larg eco st o ffailu re
Ve ry SmallScale Te st
Small ScaleT est
Large ScaleTest
Smallco st o ffailu re
Small ScaleT est
Large ScaleTest Implement
From Lloyd Provost
Successful PDSA• Think multiple tests over wide
range of conditions• Think a couple of PDSA’s ahead• Scale down the size• Learn from the last experience
3 Questions• What are we trying to accomplish?
• How will we know that a change is an improvement?
• What changes can we make that will result in an improvement?
Nolan
Change Thinking
• It is NECESSARY to be successful– So….. get started!
• It may not be SUFFICIENT to be successful only a few times– So……keep going!
• Build up data, experience and evidence over time! – This is true learning!
Summary• Keep focused on Aim – Measure –
Change• Changes are “small experiments”• Experiment wisely – PSDA• Learn from small changes over wide
conditions before implementing widely• Get started and keep going